Psychological impact of the COVID‐19 pandemic on hospital workers in Kobe: A cross‐sectional survey

Abstract Aim Many health‐care workers exposed to coronavirus disease 2019 (COVID‐19) are psychologically distressed. This study aimed to investigate the psychological impact of the COVID‐19 pandemic on hospital workers under the emergency declaration in Japan. Methods This cross‐sectional, survey‐based study collected sociodemographic data and responses to 19 stress‐related questions and the Impact of Event Scale‐Revised (IES‐R), which measures post‐traumatic stress disorder (PTSD) symptoms, from all 3217 staff members at Kobe City Medical Center General Hospital from April 16, 2020 to June 8, 2020. Exploratory factor analysis was applied to the 19 stress‐related questions. Multiple regression models were used to evaluate the association of personal characteristics with each score of the four factors and the IES‐R. Results We received 951 valid responses; 640 of these were by females, and 311 were by respondents aged in their 20s. Nurses accounted for the largest percentage of the job category. Women, those aged in their 30s–50s, nurses, and frontline workers had a high risk of experiencing stress. The prevalence of stress (IES‐R ≥ 25) was 16.7%. The psychological impact was significantly greater for those aged in their 30s–50s and those who were not medical doctors. Conclusions This is the first study to examine the stress of hospital workers, as measured by the IES‐R, under the emergency declaration in Japan. It showed that women, those aged in their 30s–50s, nurses, and frontline workers have a high risk of experiencing stress. Health and medical institutions should pay particular attention to the physical and psychological health of these staff members.


INTRODUCTION
In December 2019, a new infectious disease outbreak was reported in Wuhan, China 1 ; this was designated as coronavirus disease 2019 . 2 The World Health Organization declared COVID-19 a pandemic on March 11, 2020. A previous study from Wuhan showed how this unprecedented situation impacted the mental health of frontline hospital workers, who reported psychological problems, such as anxiety, depressive symptoms, anger, and fear. 3 Tackling the mental health of hospital workers during this pandemic is essential and will strengthen the capacity of health-care systems. 4 Previous studies have reported on hospital workers' mental health as impacted by infections, such as the 2003 severe acute respiratory syndrome (SARS), 5,6 2009 (H1N1) influenza, 7,8 and 2015 Middle East respiratory syndrome (MERS). 9 Mental health outcomes and associated factors among health-care workers related to COVID-19 have already been reported in many counties worldwide. [10][11][12][13][14] In a meta-analysis by Serrano-Ripoll et al., sociodemographic factors (younger age and female gender), social factors (lack of social support and stigmatization), and occupational factors (working in high-risk environments, specific occupational roles, and less specialized training and job experience) were identified as factors associated with the likelihood of developing psychological problems. 15 In these systematic reviews, however, there are no reports related to COVID-19 in Japan. 15, 16 We have previously reported on the psychological impact of the 2009 (H1N1) pandemic on hospital workers 7,8 and this study extends our work by examining whether COVID-19-related work is associated with mental health problems in Japan. The current study was initiated on April 16, 2020, after the first state of emergency was declared on April 7, 2020. During this time, the first number of infections had peaked, and the entire country was extremely tense. This survey is the first to be conducted under Japan's declared state of emergency to determine the stress status of hospital workers using the Impact of Event Scale-Revised (IES-R). The IES-R measures PTSD symptoms in survivorship after an event.
On March 3, 2020, Kobe City Medical Center General Hospital (KCGH) admitted its first COVID-19-infected patient in Kobe, and by the end of October 2021, 1036 patients with severe COVID-19 had been admitted. At the beginning of the outbreak, in April 2020, nosocomial infections occurred among seven inpatients and 29 staff members, and 349 employees were requested to standby at home in quarantine to prevent the spread of infection. We believe that hospital workers experienced more severe physical and psychological stress than ever before.
To clarify the impact of the COVID-19 pandemic on hospital workers, we distributed questionnaires to staff members working in a designated medical institution for COVID-19 in Kobe, Japan. We then investigated the psychological impact of the COVID-19 pandemic on hospital workers and how it varied by the characteristics of gender, age, job, and work environment.

Study setting and participants
This was an observational, hospital-based study. In April 2020, There were 19 questions related to stress ( The IES-R is a self-report measure of current subjective distress in response to a specific traumatic event. This 22-item scale comprises three subscales representative of the major symptom clusters of post-traumatic stress: intrusion, avoidance, and hyperarousal. 17 The respondent is asked to report the degree of distress experienced for an item in the past

Data analysis
The characteristics of the participants were summarized as numbers and percentages for categorical variables, and as mean and standard deviation (SD) for continuous variables.
In our previous study, during the H1N1 influenza pandemic, we performed an exploratory factor analysis and identified four factors for evaluation (anxiety about infection, exhaustion, workload, and feeling of being protected) using a stress-related questionnaire survey among hospital workers. 7,8 In the present study, confirmatory factor analysis (CFA) was conducted to confirm the same four-factor structure tested by the stress-related survey among the employees engaged in providing health-care services during the COVID-19 pandemic. The robust maximum likelihood estimator was used as the data were not normally distributed. Model fitting was assessed using the following indices with their respective cut-off values: goodness of fit index (GFI) >0.9, adjusted GFI (AGFI) >0.9, comparative fit index (CFI) >0.9, and root-mean-square error of approximation (RMSEA) ≦0.08.
The total score of questionnaire items for each of the four factors was calculated. Each score of each factor and the IES-R were compared between strata of each personal characteristic using either Student's t-test or analysis of variance. We also evaluated the association of personal characteristics with each score and the IES-R using multiple linear regression models. Participants with missing data were excluded from the regression analyses. The association between participants' characteristics and psychological impact (IES-R) was tested using Fisher's exact test, and a two-sided exact p value was reported. Two-sided p-values <0.05 were considered statistically significant.
All analyses were performed using R statistical software (Version 4.1.0). For the CFA, the lavaan package (Version 0.6-8) was used.

Regression analysis
The data of 951 (29.6%) participants were included in the regression analysis. Table 3 lists the estimated associations of the sociodemographic characteristics with the total score for each of the four factors and the IES-R. The independent variables were gender, age group, job, being asked to standby at home, exposure to COVID-19, experience of the Great Hanshi-Awaji Earthquake, and experience of engagement in DMAT. The dependent variables were Factors 1, 2, 3, and 4, and the IES-R score.
For Factor 1, "anxiety about infection," workers who were asked to standby at home had more anxiety than workers who were not asked to standby at home (β = 0.98, p < 0.001). Regarding gender, females reported higher levels of anxiety than males (β = 0.69, p = 0.003). Workers in their 40s experienced higher levels of anxiety than workers in their 20s (β = 0.55, p = 0.034). Related to job category, nurses and others had higher levels of anxiety about infection than medical doctors (nurses: β = 1.80, p < 0.001; others: For Factor 2, "exhaustion," workers in their 30s, 40s, and 50s reported feeling more exhaustion than workers in their 20s For Factor 3, "workload," workers who were asked to standby at home reported higher workload than workers who were not asked to standby at home (β = 0.32, p < 0.018). Workers in their 30s, 40s, and 50s reported more demanding workload than those in their 20s (30s: β = 0.44, positive on clinical concern for PTSD ( Table 4). The results of detailed demographic data for the severe group who were suspected of having PTSD were described in Table 5. The psychological impact was significantly related to the job (p = 0.006). In regression analysis, the total IES-R scores varied by age and job. The total IES-R scores of workers in their 30s, 40s, and 50s were higher than those of workers in their 20s (30s: β = 2.7, p = 0.018; 40s: β = 3.37, p = 0.005; 50s: β = 3.96, p = 0.012).
Examined by job category, the total IES-R score of nurses and others was higher than that of medical doctors (nurses: β = 4.38, p = 0.004; others: β = 5.65, p = 0.000).
In regression analysis, we included the experience of the great Hanshin-Awaji earthquake and experience of engagement of DMAT as independent variables. We investigated whether the experience of the Great Hanshin-Awaji Earthquake would be a vulnerability factor in reexperiencing trauma, and whether the experience of DMAT participation would be a protective factor through prior education. Regression analysis showed that these experiences did not influence the total score for each of the four factors and the IES-R.

DISCUSSION
This is the first study examining stress of hospital workers, as measured by the IES-R, under the emergency declaration in Japan. The study identified that among health-care workers, women, those in their 30s-50s, nurses, and frontline workers faced multiple high-risk factors while treating patients with COVID-19.

Stress and quarantine
At the beginning of the COVID-19 outbreak, nosocomial infections occurred, and 349 employees were required to standby at home to prevent the spread of infection. Workers who had to be quarantined felt higher levels of "anxiety about infection" and a higher "workload" than those who were not quarantined. However, quarantined workers also had a stronger "feeling of being protected" than nonquarantined workers. Continuous communication between health-care workers and managers, including the provision of upto-date facts about the progression of the outbreak, conveys institutional support. Similarly, it is essential that managers take steps to mitigate feelings of social isolation and stigmatization, especially among quarantined hospital health-care workers. 15

Stress and gender
In our study, females experienced higher levels of anxiety and felt less well-protected than did males. In contrast, "exhaustion," "workload," and the IES-R scores did not significantly differ between genders. Similar results have been reported previously. Female gender has been consistently associated with higher levels of stress [19][20][21] and anxiety, 10,[20][21][22][23][24][25] whereas no consistent association has been found with PTSD. 15 Women were more prone to anxiety and stress, and seemed to require more attentive care.   Hospital workers in their 30s, 40s, and 50s were more exhausted and reported that they had a greater workload than workers in their 20s. In terms of sociodemographic factors, younger age is a risk factor for burnout. 27 Our results, however, showed that older workers had greater risk for exhaustion during the emergency declaration. Another study in Japan also showed that older workers experienced more general distress than workers in their 20s. 28 The COVID-19 pandemic was more prolonged than the events addressed in previous studies, which may have affected the results.

Stress and profession
Examined by job category, nurses, and others were significantly more anxious about infection and becoming exhausted, but they perceived receiving less protection than did medical doctors. Reported "workload" was significantly higher for nurses than medical doctors. Moreover, the total IES-R score was significantly higher for nurses than medical doctors.
Similar results were reported in studies of the 2003 SARS outbreak 5,29 and the 2009 influenza pandemic (H1N1) in Japan. 8 Another study of the COVID-19 pandemic yielded similar results. 10 Nurses are more likely to develop PTSD, 30 anxiety, 31 stress, 32 and burnout. 33  Based on the findings of this study, starting in July 2020, we shared the information on the cover of the electronic medical records system to enable all staff members to access it equally. It is necessary to examine whether this method has led to improvements.

Stress and place of posting
Hospital workers in high-risk environments (frontliners) experienced significantly higher levels of "exhaustion" and a higher "workload" than workers in low-risk work environments (non-frontliners  (IES-R ≥ 26). 10 However, a study conducted from February 19 to March 13, 2020 among health-care workers during Singapore's COVID-19 outbreak showed a lower prevalence (7.7%) of stress (IES-R ≥ 24) compared to that in our study, 34 a difference that may be related to the period and place that posed maximal stress.
The "feeling of being protected" factor did not significantly differ between work environments. The total score for the "feeling of being protected" factor was low for workers in both high-and low-risk areas. This could be because during the COVID-19 pandemic in Japan, especially in the latter half of April and May 2020, national and local governments enacted infection-control activities, but did not provide hospital workers with information about protection against or compensation for COVID-19 infection acquired in the course of hospital duties. The supply of protective equipment was inadequate.
Some staff required alternative accommodation to reduce the risk of infecting their families. In preparation for a pandemic, some studies have emphasized the need for communities and employers to take all reasonable precautions to prevent illness among health-care providers, as well as to provide reliable compensation if workers become ill while carrying out required duties. [35][36][37] Motivated by our study results, our hospital's director began the practice of sending regular messages of comfort, encouragement, and appreciation to the staff. We also received letters of appreciation and gifts from citizens and companies. Special allowances were also provided to all employees. We will need to examine how such efforts improve mental health among hospital health-care workers.
This study has several limitations. First, the present study used the CFA analysis to replicate the factors and their comprising items that were confirmed in the H1N1 influenza pandemic. However, the limitation of conducting CFA by the previous model may dismiss other models that fit more appropriately to the present pandemic.
Second, the response rate of the present study was 29.6%. A low response rate can give rise to sampling bias if the nonresponse is unequal among the participants. However, the results of this study were consistent with those of previous studies and seemed to reflect the mental health of hospital health-care workers. Third, we did not assess other common mental health problems, such as depression.
However, the association between IES and depression has been pointed out in previous studies 38 ; thus, the IES-R scores may accurately reflect the mental health of the staff. Fourth, as our study was conducted at a single health-care facility, its external validity is limited. These results, however, are similar to those of another study conducted in an urban health-care setting in Japan. 28 The study showed that female nurses, when compared with doctors who were low-risk workers, and people aged between 40 and 49 years who were high-risk workers experienced more event-related distress. This finding, which supports our analysis, suggests that our result has some degree of external validity.

ACKNOWLEDGMENTS
We thank the hospital staff of Kobe City Medical Center General Hospital for their assistance in this study. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. PTSD of clinical concern (≥25) 159 (16.7) Abbreviations: IES-R, Impact of Event Scale-Revised; PTSD, post-traumatic stress disorder.
T A B L E 5 Psychological impact of the pandemic by participants characteristics